BORANG PERMOHONAN / APPLICATION FORM PROGRAM : PROGRAMME :

KURSUS PENGAJIAN SYARIAH KURSUS PENGAJIAN USULUDDIN

*Pilihan Modul : 1( ) 2( ) 3( ) *Cawangan / Branch : APIUM ( ) MAINS( )

KURSUS BAHASA ARAB KURSUS KEMAHIRAN MEMBACA AL-QURAN

*Peringkat : : 1( ) 2( ) 3( )

*Pilih salah satu. Sila tanda () Nama Penuh :________________________________________________________________________ Full Name

Jantina : _______________________________ Warganegara : ________________________________ Gender Nationality No. K/P : _______________________________ (B) __________________________________________ I/C No. (Baru/New) (Lama/Old) Tarikh Lahir : ___________________________ Kelayakan Akademik : __________________________ Date Of Birth Academic Qualification Nama Majikan : _________________________ Jawatan : ____________________________________ Employer’s Name Designation Alamat Majikan : _____________________________________________________________________ Employer’s Address

_____________________________________________________________________ Alamat Surat-Menyurat : _______________________________________________________________ Correspondence Address _______________________________________________________________ No Telefon : ________________________ (Pejabat/Office) Faks/Fax : ______________________ Telephone No. ________________________ (Rumah/Residence) No. H/P : _______________________ Saya mengaku bahawa semua keterangan dan bukti yang saya berikan di dalam permohonan ini adalah benar. Saya sedia maklum bahawa pihak Pusat Pendidikan Berterusan Universiti Malaya (UMCCed) berhak menolak permohonan ini atau menarik balik tawaran program pada bila-bila masa sekiranya mana-mana keterangan atau salinan sijil-sijil yang dikemukakan adalah tidak benar. I declare all the information and proof given in this application is true. I understand that University of Malaya Centre for Continuing Education (UMCCed) has the right to withdraw or terminate this offer at any time if the information or copy of certificate (s) given by me in this application are false.

_________________________ __________________________

Tarikh/Date: Tandatangan Pemohon/Applicant’s Signature

PERHATIAN : Sila sertakan salinan Sijil Pelajaran Malaysia (SPM) dan Kad Pengenalan yang telah disahkan benar.

a

Sila isikan ruangan atau tandakan () di mana yang sesuai. Please tick ( ) corresponding to your answer. 1. Daripada manakah anda mendapat tahu mengenai UMCCed dan program yang ditawarkan ini? How did you find out about UMCCed and the programmes offered?

Iklan Akhbar Advertisement in a newspaper

Pelajar atau Graduan UMCCed Students or Graduates of UMCCed

Iklan di internet Online Advertisement

Pameran Pendidikan Education Fair

Iklan Radio Radio Advertisement

Carian di internet Online Search

Brosur Brochure

Iklan Billboard Advertisement on Billboard

Poster Poster

Rakan Friends

Makluman Majikan: Informed by the Employer:

Media Sosial: Social Media:

i. Emel E-mail ( ) i. Facebook ( )

ii. Poster Poster ( ) ii. Instagram ( )

iii.Surat Letter ( ) iii. Twitter ( )

Lain-lain (Sila nyatakan): ________________________________________ Others (Please specify):

2. Jika sumbernya adalah melalui iklan akhbar, sila tandakan akhbar berkaitan: If you found out about us through an advertisement in a newspaper, kindly specify below:

The Star News Straits Times

Berita Harian Utusan Malaysia

Kosmo Harian Metro

Sinar Harian The Sun

Sin Chew Daily Malaysia Nanban

Lain-lain (Sila nyatakan): ________________________________________ Others (Please specify):

SOAL SELIDIK PERMOHONAN PROGRAM PROGRAMME APPLICATION SURVEY

b

3. Adakah ini pertama kali anda mengetahui berkaitan UMCCed? Is this your first time hearing about UMCCed?

Ya Tidak Yes No

4. Sila nyatakan akhbar utama pilihan anda mengikut keutamaan: Please state the daily newspapers of your choice according to your preference:

i. ___________________________________

ii. ___________________________________

iii. ___________________________________

TERIMA KASIH THANK YOU